1. Welcoming Sexual Health and HIV Strategy
We have consistently argued that a National Strategy for Sexual Health and HIV is necessary to direct attention and support to this vulnerable area of health need. We are very pleased that the Strategy is now in existence and praise the government and officials for the hard work that so clearly went into it. We believe that the Strategy, as published, is courageous in its scope and has avoided many of the pitfalls and concerns that were expressed during its production. We welcome much of the Strategy but have focussed below on some concerns where the Strategy falls short of our hopes and expectations.

2. Cross-departmental action
We had hoped to see a broad Strategy that encompassed the work of other government departments, as the Teenage Pregnancy Strategy did. We are therefore disappointed that the focus is primarily on action to be taken by the Department of Health. Furthermore, it is our opinion that, even within Health, the Strategy takes an overmedicalised approach to its subject with the result that sexual health is depicted in terms of the management of disease, rather than the promotion of health and wellbeing. It thinks largely in terms of what health staff in clinical settings can do. It fails to look at the wider aspects of public health or how achieving changes in the social climate might have an impact on sexual health. Many of the factors that determine sexual health and well-being are outside of the remit of health personnel. We suggest that the Department of Health takes full advantage of the current momentum to engage national and local decision-makers beyond the health sector and to promote the ethos of the Strategy through a robust implementation programme.

3. Government Support
As we argued initially, sexual health is an area vulnerable to the prejudices of health professionals, the media and the general public, and is often compounded by racial and homophobic discrimination. It requires strong political commitment to ensure that health structures prioritise this work. We are concerned that, with the move to new structures in the NHS and with competing priorities being accorded the status of National Service Frameworks, this Strategy does not appear to carry the full weight of government support or to be made a priority appropriate to its importance. Sexual health has, as the Strategy affirms, a major impact on health and well-being. Rising rates of HIV and a number of sexually transmitted infections (STIs) a crisis of capacity in Genito-Urinary Medicine and wider family planning services, and escalating HIV treatment costs indicate that a sustained, integrated initiative is urgently needed. The Strategy needs to have very clear and high-profile political support to achieve its objectives.

Furthermore, Ministers across Government must take a stand to work towards the social climate where sexual health concerns are less a cause for shame, stigma, embarrassment and concealment. Sex and relationships education in schools is an ideal forum in which to tackle discrimination and promote open attitudes. However the Strategy fails to consolidate the wide range of departmental initiatives (e.g. Healthy Schools, PSHE sex and relationships education, Sure Start, Connexions) - just one example of the absence of cross-government backing of the Strategy during its production and launch.

4. Performance Indicators
We have separately submitted a response to the performance indicators published in advance of the Sexual Health and HIV Strategy. We remain concerned about some of the targets identified in the Strategy. In particular, it is unclear whether some of the targets are to be applied locally or nationally and, if nationally, how local health planners should respond. It is unclear whether the target to reduce by 25% HIV and gonorrhoea refers to infections acquired or diagnosed in the UK. There is a confusion of target dates, the Strategy has been referred to as a ten-year Strategy yet the targets set are for completion before 2012 – whilst the rationale for the specific dates set is unclear. With such a long lifetime, the Strategy’s targets and standards require continual assessment to ensure that they remain realistic and are on course. There is no apparent mechanism for this in the document.

5. Funding
The devolution of commissioning to PCTs has the potential to provide greater flexibility to develop services that reflect local needs. This radical shift must be accompanied by appropriate national resources to make a difference to local practice. The commitment to provide a £47.5 million ‘start-up’ fund is positive, however, the range of costly targets and projects specified for local implementation (on abortion, chlamydia screening, HIV testing and prevention) will immediately place unprecedented demands on local budgets. The extensive prevention work (such as enhanced outreach services, local needs assessment) which the Strategy requires of providers, in addition to developing and meeting local targets, demands long term investment in staff and services. Some areas, in particular family planning, termination of pregnancy and GUM services, HIV prevention for gay men and African communities are unlikely to be given precedence by commissioners, therefore the Department of Health must ensure that mechanisms are incorporated to protect and promote these vulnerable services following the devolution of commissioning to PCTs.

6. Staffing
The Strategy aims to increase the number of professionals working in sexual health services and to make the best use of their talents, yet it does not reveal how providers are expected to overcome the joint hurdles of staff shortages and few available resources. Staff working in the NHS- particularly in primary care and GUM services are overburdened and working in resource-stretched environments. The Strategy’s promotion of enhanced open access and outreach services is to be welcomed, however it must be accompanied by an assessment of the workload implications for professionals. The Strategy commits to supporting professionals’ increased education and training needs, yet there is no explanation of how this is to be funded or managed locally.

7. Service Structure
We believe that the remodelling of services in a layered structure will provide clarity and vision for users and practitioners. In order to inform current practice, the model must be substantiated with practical guidance for care providers and the public in order to facilitate pathways to services which experience problematic access i.e. GUM, contraception, abortion and services for gay men. Whilst the promotion of long-term objectives such as service networks and primary care teams with a special interest in sexual health are welcome, the Strategy needs to support providers by addressing obstacles to the implementation of the tiered service structure from April 2002. A plan for transitional action, including robust commissioning guidelines, is therefore appropriate.

8. Independent Advisory Group/ National Monitoring and Evaluation Programme
The ‘frontline’ ethic at the heart of the Strategy is to be welcomed, however the process outlined by the Strategy threatens to create an intermediary vacuum. The targets require periodic monitoring and evaluation by an independent national body, whilst the new Sexual Health Unit must remain informed about local commissioning trends and practice. We suggest that the implementation incorporates an independent advisory group to assess the progress of the Strategy and to ensure synergy between local and national level.
The long-term focus of the Strategy is positive. It needs to be accompanied by comprehensive budgetary provision to enable commissioners to implement the reforms and modernise local services. A commitment to sexual health as an urgent national policy priority would give impetus to the process and prolong the value of this initiative.
We hope that these comments are constructive and that we will be able to maintain a dialogue with the government as implementation plans for the Strategy are developed and put into practice.
Yours sincerely

Anne Weyman OBE
Chief Executive
FPA

On behalf of:
BMA Foundation for Aids
National Aids Trust
Society for the Advancement of Sexual Health
Sex Education Forum
Terrence Higgins Trust

Endorsed by:
British HIV Association
Herpes Viruses Association
National Children’s Bureau
Pan London HIV Providers Consortium
Positively Women

Copy sent to:
Rt Hon Alan Milburn MP, Secretary of State for Health
Yvette Cooper MP, Parliamentary Under Secretary of State for Health